septjc.html

Universityof
Virginia HealthSystem

Nutrition Support E-Journal
Club

September 2007

Greetings,

We just completed our September session with trainees from Texas,
Maryland, Mississippi, and Missouri. We had a great week, with
some interesting cases and wonderful discussions. The trainees
were treated to balmy summer weather now that the humidity has eased,
and we were able to dine outside for our night out.

The journal club article this month discusses physiologic changes
that result after starting enteral feeding in patients that had
received long-term TPN.

This was a prospective, observational study of 100 patients with GI
fistulas that received "long-term" parenteral nutrition (PN), and then
began enteral nutrition (EN). The patients were subcategorized
into three groups; those that received PN less than 15 days (n=2),
15-30 days (n=23) or greater than 30 days (n=52).

The authors reported that after GI fistula losses "were controlled"
EN was initiated at 500 calories/day, then advanced by ¼ of the final
goal each day to reach goal calories (~ 35 calories/kg) on day 4.

Inclusion and Exclusion Criteria were:

The study enrolled patients with a GI fistula between April 2001 and
July 2002 that had an intact gut without massive loss of GI fluid
(never defined). The exclusion factors were diabetes mellitus,
tumor, s/p chemo or radiation therapy, and hospitalization < 7
days.

Major Results reported by authors:

The authors reported that the alkaline phosphatase, GGT, and total
bilirubin levels significantly increased in the first several days
after starting enteral feeding, then levels decreased either to normal
(total bilirubin) or to pre-enteral feeding values (alk phos and
GGT). There were no significant changes in transaminase levels or
direct bilirubin.

The SIRS score was significantly increased after initiation of
enteral feeding in those patients that had received PN greater than 15
days. The group receiving PN 15-30 days had increased SIRS score on day
1 after starting EN, but SIRS score returned to previous levels on day
3 of EN. The group without enteral nutrition greater than 30 days
had increased SIRS score on days 1 and day 3 after starting EN with
return to previous levels on day 5 of EN. Increased WBC and fever
were reported in 26 patients in the first 3 days of EN, but only 7
patients (26% of those with fever) had positive catheter tip
cultures. Stool frequency and the incidence of diarrhea (defined
as > 3 stools/day) were significantly increased after the start of
EN.

Three patients developed cholecystitis and cholestasis within the
first 3 days after starting EN. Five patients were reported to
have gallbladder sludge by ultrasound.

Author's Conclusions:

The investigators use the term "enteral refeeding syndrome" to
describe the lab changes and increased SIRS scores noted in their
patients following the start of EN after a period of gut rest/
PN. They postulate that this syndrome is caused by cholestasis
and atrophy or edema of the intestinal mucosa resulting from long-term
fasting, and that the only solution for this "syndrome" is continued
enteral feeding.

Evaluation:

This was not a randomized or blinded study, and there was no
comparison group that did not begin EN. The investigators simply
described physiologic events that occurred after starting EN. In
such a design, without a control group it is not appropriate to assume
that starting EN was the cause of these changes. The authors
report that catheter-related sepsis was suspected in 26 patients due to
fever and elevated WBC after starting EN, but that a positive catheter
tip was found in only 7 patients. However, a catheter related
sepsis is not the only cause for fever, increased WBC or elevated
hepatic enzymes. Pneumonia, urinary tract infection, and
medication related reactions are among the myriad of other factors that
can also contribute to these changes, and frequently occur in
hospitalized patients. No mention was made of antibiotic or other
medication changes that occurred after a patient developed fever or
SIRS.

The authors reported increased stool output after initiation of
enteral feeding, and an increased number of patients with more than 3
stools per day on days 1, 3, 5, and 15th day after starting
EN. However, there is no record of medications given through the
feeding tube such as sorbitol-containing liquids and elixirs, laxatives
and stool softeners, or enteral electrolyte replacement. Finally,
the author provides no information about the underlying etiology of 100
patients presenting with fistula in a 15 month period-one wonders if
there are factors relating to the underlying disease that contributed
to lab changes associated with starting enteral feeding. The
article does not provide information if this is a specialty facility
that so many patients would have fistulas, or why there would be such a
high incidence of fistula formation.

Importantly, although mean body temperature was reported to be
statistically increased after starting enteral feeding, a glance at the
tables tells us that body temperature increased from 37.1 +/- 0.8 to
only 37.3 +/- 0.7. A temperature of increase of 0.2 degrees
Celsius is not a clinically significant increase in temperature.
Likewise, there is no evidence that these changes in lab values or
physiologic variables resulted in significant clinical
sequelae.

Although it is not possible to ascribe cause and effect to enteral
feeding with the current study methods, it IS possible that restarting
EN after a period of "GI tract starvation" may have physiologic
consequences. The observational nature of this study is
appropriate to form theories and collect data necessary for a
randomized study.

Our Take home message:

Although the theory of "enteral refeeding syndrome" should be
investigated further, there is no evidence that there is a clinically
significant sequelae caused by the initiation of enteral feeding after
a period of gut rest, nor that it is in any way related to what is
currently thought of as "refeeding syndrome."

Other News:

•1) Check out the
latest Practical Gastroenterology articles/info at:

http://www.uvadigestivehealth.org/
Scroll down to GI Nutrition to the pull down menu with links within
the GI nutrition site and look for "Nutrition Articles in Practical
Gastroenterology." The August and September articles
are:

¨ Krenitsky, J., Makola D., Parrish, C. Parenteral Nutrition in
Pancreatitis is Passé: But Are We Ready for Gastric Feeding? A Critical
Evaluation of the Literature - Part I. Practical Gastroenterology
2007;XXXI(9):92.